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Author: amberericksonblog

In previous blog posts I have discussed the potential impact of the current public health reimbursement rates on local health departments and the communities they serve, the need for improved funding for public health emergencies, and the necessity of using data to inform spending priorities. A potential way to curb the negative impact of scarce financial resources for local public health agencies can be found in strategic and community health improvement planning.

The National Association for City and County Health Officials (NACCHO) defines community health improvement planning as a process that identifies “priority issues, develops and implements strategies for action, and establishes accountability to ensure measurable health improvement”. According to NACCHO, strategic planning “provides a local health department and its stakeholders with a clear picture of where it is headed, what it plans to achieve, the methods by which it will succeed, and the measures to monitor progress”.

Through strategic and community health improvement planning, local health departments can effectively assess the financial realities of potential interventions or programs needed to address community based public health priorities and plan accordingly.

Luckily here in Georgia, several of our local health districts and our state health department have decided to apply for public health accreditation. In fact, 3 of the 18 public health districts in Georgia are now accredited. This means that all over the state, public health is prioritizing public health interventions based on current data and assessing the financial impact of public health priorities.

Some examples of how these types of planning efforts can positively affect local public health are:

The Georgia Department of Public Health’s State Health Improvement Plan has identified the reimbursement rate issue (as discussed here) as a priority and is working towards alleviating this problem state-wide.

The North Central Health District’s Strategic Plan has identified the need for alternative clinic hours to improve access to care as priority and is now offering alternative hours in several clinics. This effort has increased the number of patients able to be seen, therefore increasing the revenue of those clinics which has lead to the ability to offer new public health interventions.

These planning processes and public health accreditation may be new to public health here in Georgia and across the country but they are a step in the right direction.

In preparing for this week’s blog I spent some time speaking with my district’s Administrator on financial management topics of concern to local health departments (LHD). During this conversation, I learned that local public health clinics are getting reimbursed for the same medical care given in the private industry but at a much lower rate or not at all.

Most people think that public health services are free. However, U.S. public health funding has been steadily declining over the past several years and clinical services have been part of those cuts.

An example of these cuts to clinical services occurred within the Georgia Department of Public Health (DPH) in 2014. This significant loss of funding has led to a massive restructuring in how health services are funded and provided at all 159 local county health departments in Georgia. The Title X Family Planning program funded by the U.S. Department of Health and Human Services (HHS) was created in 1970 as part of the Title X of the Public Health Service Act and provides “individuals with comprehensive family planning and related preventive health services”. Instead of these funds being awarded to DPH like they had historically been done, the funds were awarded to a consortium of federally qualified health centers (FQHCs) based out of Atlanta that provided more than 170 locations around the state. This was a loss of $7.8 million over a three-year period for DPH but with the cost of restructuring and the loss of patients the cost is most likely higher.

According to a report published in 2014 by NACCHO, LHDs need to earn revenue “through third-party reimbursement” to help ensure that they are able to “provide essential services, conduct core public health functions, and improve the health and well-being of their communities”. This report also states that one of the biggest barriers is that with the Affordable Care Act (ACA) there is a “push towards the “medical home” or using primary care providers with bundled payments for managed care. Due to this shift in service delivery, private insurance companies may not recognize health departments’ clinical services as part of the medical home”.

So what happens when public health funds are cut left and right and they are told to earn revenue but insurance companies won’t play with them because of how the ACA was written?

Last month, the CDC reported that the total number of STD cases in the U.S. had reached an all time high. They attribute some of this increase to fewer public health clinics and reduced access to STD testing and treatment. If we don’t find a way to properly fund our LHDs, reports like this will just continue.

The Public Health Emergency Preparedness (PHEP) and Hospital Preparedness Program (HPP) budgets have consistently been cut for the past decade. However, our known and unknown public health threats seem to be increasing.

According to the latest Trust for America’s Health Report, the PHEP budget that provides support for states and localities to prepare for and respond to all types of disasters has dropped from $940 million in FY 2002 to $651 million in FY 2016. The HPP budget provides funding for healthcare systems to respond to and recover from health emergencies and has seen a 50% cut over the years from $515 million in FY 2004 to $255 million in FY 2016.

In 2009, at the start of all of the budget cuts, we saw our first large scale pandemic in the 21st century. Lucky for us, the U.S. government had been spending money on pandemic flu planning for years. The problem was, the 2009 H1N1 flu pandemic didn’t happen according to the plan. It was supposed to be severe and start in Asia, and instead the pesky flu pandemic had mild severity and started in Mexico. Post H1N1, our government took it upon themselves to cut PHEP and HPP funds and give additional funds for H1N1 planning. I was working for the Wyoming Department of Health as their Emergency Preparedness Epidemiologist at this time and I can promise you that we had already revised our plan and responded accordingly. We didn’t need funds to do it after the fact. What we needed was our general PHEP and HPP funds to remain steady (or in a dream world – increase) so that we could look at what our actual needs in preparedness were (i.e., training and increased surveillance efforts).

Fast forward to 2014, additional cuts have been made to PHEP and HPP. One of them I deem to be so crucial it may (again this is my opinion) have led to our hospital systems not being prepared enough to handle an Ebola patient. This was more than $100 million cut to the HPP fund that led to the cut in training programs that included how to ‘don and doff’ personal protective equipment (if you are unfamiliar with the Ebola situation in Texas, the unfamiliarity with donning and doffing procedures is what ultimately led to the spread of Ebola to the healthcare personnel). From late 2014-2015, epidemiology and preparedness programs across the country worked tirelessly on active surveillance, training internal and external partners, and planning. Then in mid 2015, we were blessed with money to plan for our response to Ebola. We hired people to plan for something that we had just spent 9 months planning for. (Can anyone say waste of funds?) These funds were to be used from May 2015-September 2016.

Does anyone know what happened in February 2016? The World Health Organization declared a public health emergency for Zika.

Could we use that wonderful Ebola planning money to support preparedness and/or response activities for Zika? Nope.

So here we have 9 months of planning and response efforts already underway and the government finally decides what public health officials have been telling them all along. We need money to plan in order to prevent local transmission. Maybe if we had received those funds, along with not being cut again this year in PHEP and HPP, we wouldn’t have the situation that we do in Miami.

In order to protect the public’s health, public health practitioners need to be able to plan for health threats appropriately. If budgets continue to get cut then we will continue to plan for things that have already happened. This can, and in my opinion has, left us with improperly trained staff and strained resources which makes us vulnerable to emerging and re-emerging public health threats. This can easily be fixed by using the situational awareness information that comes from local, state, federal, and global public health agencies to strategically plan for what our country’s public health needs are instead of planning budgets based on what just happened.

I have been trying to write this blog for 3 days now and every time I start to research topics to write about I end up just getting more frustrated with our federal budget system. As I reflect on the federal budget process, I keep on going back to 2 lessons that my grandparents taught me back in 1993 when my brother and I spent the summer with them.

Lesson 1. Don’t spend more than you have.

My grandmother taught me how to budget for things/needs (i.e., snacks at the community pool and my end of the summer shopping session that we had planned) based on the income I earned (i.e., babysitting and allowance received from chores completed). From that point on I knew that you couldn’t plan on spending more than what was brought in (no matter how cute those mary jane shoes were).

There is a line in the Concord Coalition Exercise that I keep on going back to. “The economy continues to improve, and the deficit dropped dramatically to $439 billion in 2015.” What?! That is the deficit, not our debt (which is drastically more). This means that our federal government wants to spend $439 billion than we are going to be bringing in for the year. The next line in the exercise makes me laugh but it isn’t funny. “Yet, the structural problems in the budget remain, and deficits are projected to rise again beginning in 2016.” That increase that the Concord Coalition mentions is projected at just under $600 billion. Something needs to give, which leads me to the second lesson I learned from my grandparents that summer.

Lesson 2. Don’t waste your time on things that don’t work.

That summer I spent with my grandparents, they got new neighbors with boys around mine and my brothers ages. I had a huge crush on the boy that was a year or 2 older. One day, my brother and I were helping my grandfather with something involving spray paint (I honestly have no idea what we were doing but spray paint was involved). The new neighbor boys came outside and wanted us to play with them. My grandfather told us that I had to finish helping him first. He then gave me the spray paint can and told me to shake the can until it was ready. I asked how to tell if it was ready and he said when the ball inside stopped making noise. So I shook the stupid thing for what seemed like forever. After a few minutes, I complained about it taking too long, he said I wasn’t done because he can still here it. He starts laughing. I shake, he laughs even harder. My grandmother comes out to take a picture of me shaking this stupid spray paint can. At this point I realize that he is messing with me so I stop. While trying to control the laughter he says that I can go play. I really learned 2 lessons from this but only 1 applies to budgets. 1. Don’t trust my grandpa when boys are around. 2. Don’t waste your time doing something that doesn’t work.

The biggest problem I found from this exercise was that some of the research conducted actually shows that some of these programs that are being kept around do not reach their desired effect. For example, one of the options for the exercise was to cut $12 billion in Department of Education Grants for Elementary and Secondary Education. The data presented to us through the exercise states “An evaluation funded by the Department of Education concluded that programs funded by those grants had no significant impact on the academic achievement, parental involvement, or homework completion of participating students relative to similar students not participating in the program.” This says to me that these programs are not working. Why are we funding things that aren’t doing what they are intended to do?

Take Away

All of our legislators need to spend time with my grandparents.

Just Kidding.

We need our legislators to take their head out of the sand, stop listening and taking things from special interest groups, and look at the data. If it doesn’t work, it gets cut. Maybe by cutting programs, we can find new and creative ways of doing things and actually see improvements to our society. Just because we have always funded or subsidized a program (I’m talking to you Amtrak), doesn’t mean we need to continue to do so. Then maybe by cutting things that don’t work, we can stop spending more than we have and start paying off China.

In my current position at the North Central Health District I manage 4 budgets. Two of which are epidemiology specific that we get from the state on a yearly basis and the other two are grant funds we have received from outside sources for work-site wellness and accreditation activities. I also manage staff that are funded through our general funds and have to maintain oversight of those costs separately.

Managing of these budgets has consisted of projecting our costs for the upcoming year, reviewing the budget with the finance office monthly, and making sure I spend down the funding we have received in an appropriate fashion. In my agency, money that is not spent has to be sent back to the funding source and this is highly frowned upon. I have considered myself to be decent at budget management purely based on the fact that I have never over or under spent and my projected costs are usually on target.

(Note: I say “usually on target” only because it is hard to project your costs when you deal with outbreaks. Threats like Ebola and Zika will drastically change your budgets in a blink of an eye. When this happens, like right now with our response to Zika, I meet with our finance office and make sure they are aware of the situation so we can plan accordingly.)

With the major budget cuts to public health across the country in combination with an increase in workload due in part to emerging and reemerging public health threats it is imperative that we, as future public health leaders, understand how to properly manage programs within budget constraints. This should involve knowing how to evaluate programs for effectiveness, advocating for those programs that are essential in order to reduce the burden of disease within our communities, and working with partner agencies to increase public health’s reach.

I have always known that there was more to financial management than just not over or under spending and I am hopeful that this class will assist in helping me understand more about the various topics that are needed to properly manage and evaluate public health programs.